‘NOTES’ Cuts Out Appendectomy Scar

A study in the British Journal of Surgery says that removing an inflamed appendix via the stomach is feasible and “promising.” The technique is known as natural orifice transluminal endoscopic surgery (NOTES).

The paper (full text plus videos here) describes the first 15 cases done at the University of Heidelberg in Germany.

There is so much wrong with this paper and the concept in general that it is hard to know where to start.

During the year from April 2010 to April 2011, 111 patients were offered the chance to have this procedure done, and only 15 agreed to do so. It appears that patients have a lot more common sense than some physicians think. The patients were carefully selected. Those with BMIs > 30 and with perforated appendicitis were excluded.

The procedure was done by inserting an endoscope orally and then through the stomach wall, but if you read only the abstract, you would miss the fact that a separate trocar was inserted via the umbilicus to facilitate the operation. Therefore, it is not a pure NOTES procedure.

Several complications occurred. The first case had to be converted to an open appendectomy because of “severe inflammation.” This was not explained in the paper but was revealed in the typically uncritical MedPage Todayarticle about it.

Two patients developed postoperative pelvic abscesses requiring what they called “laparoscopic revision,” which is their euphemism for second operations. This is very uncommon in patients without perforated appendicitis.

In one patient, a technical problem necessitated ligation of the stump of the appendix through the umbilical port. Another patient had bleeding that had to be controlled by clips. For an obese patient (curious, as only patients with BMIs < 30 were to have been included), the appendix had to be cut into two pieces because it would not fit through the opening in the gastric wall.

The median duration of the NOTES cases was 105 minutes, with a range of 59 to 150 minutes. The average time for a standard three-port laparoscopic appendectomy is about 25 to 35 minutes, which means that the NOTES takes three times as long.

The median hospital stay was 3 days, with a range of 1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy in the United States is less than 24 hours.

The heavily edited videos are worth a look — especially the fourth one, which shows that it takes at least 10 snips with the tiny endoscopic scissors before the appendix is completely divided.

Because of the two patients in the series who developed abscesses, the authors advise caution for those with purulent appendicitis and suggest doing a standard laparoscopic appendectomy instead. The problem is that the surgeon would not know that a patient has purulent appendicitis until she has looked and made what would then have been an unnecessary hole in the stomach.

Most standard laparoscopic appendectomy scars are invisible anyway. If just one patient suffered a leak of the stomach wall closure which would cause sepsis and other major complications, that would strongly negate the minimal cosmetic gain from the trans-gastric operation.

The study ended 2 years ago but was just published. I always wonder about that. What took so long? Was it rejected by other journals? You would think the authors would want this sort of breakthrough brought to light as soon as possible. Have they done more cases since then? What were the outcomes?

After reading the paper and seeing the videos, is there a surgeon in the world who would want a trans-gastric appendectomy performed on herself or a loved one? An unscientific Twitter poll indicated they would decline. A surgeon said, “Not sure if I’d answer ‘No’ or ‘Hell no,’ and I do NOTES research.”

Here’s the bottom line: Unless you have promised your patient trouble, only the most ardent proponent of NOTES could call these results “promising.”

Just because you can do something doesn’t mean you should.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5300 followers on Twitter.

About The Author

SkepticalScalpel

Skeptical Scalpel

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5,300 followers on Twitter.

Generally, “promising” denotes a positive outcome, even if it’s not giant step forward. I am thinking these surgeons have been drinking their own Kool-Aid. I am not even sure why anyone would think there needs to be an improvement on a standard appendectomy.

Agree with all of your points, but recall how long the first lap appys took and how poor the early tools were. Also, not sure how a hole in a healthy stomach is different than a hole in a healthy abdomen. Clearly, NOTES tools and procedures are not ready for prime time today, but who knows what time will bring?

Bob, thank you for reading and commenting. Here’s the difference between a hole in the stomach and a hole in the abdominal wall. A hole in the abdominal wall that does not heal well may rarely result in a hernia needing repair. A hole in the stomach wall that doesn’t heal well will allow gastric juice to leak into the peritoneal cavity resulting in a serious infection with occasional systemic sepsis and even death.